ON PATIENT SATISFACTION WITH ANESTHESIA FOR RECONSTRUCTION OF THE ANTERIOR CRUCIATE KNEE LIGAMENT

Background / Aim. Patient satisfaction, when it comes to anesthesia, is more difficult to assess than in any other medical specialty. The aim of this study was to construct a tool for assessing patients' satisfaction with anesthesia, and then examine the effects of postoperative care provided by anesthesiologists on patients’ satisfaction. Methods: The study included patients undergoing general anesthesia, who were considered ASA 1 and ASA 2 class. Patients were divided into three groups: Group 1 included 74 patients who had postoperative visit performed by an attending anesthesiologist; Group 2 included 70 patients who had postoperative visit performed by a nurse anesthetist after surgery; and Group 3 included 74 patients who did not have postoperative visit during postoperative care by an anesthesiologist nor a nurse anesthetist. The tools used in the research were Anesthesia patient satisfaction questionnaire specially designed for this study and Post Anesthetic Recovery Scoring System (PAS). ANOVA and Pearson’s correlation coefficient were used for estimating the statistical significance of the obtained results between the groups. Results: Association between an objective assessment of the post-operative status of patients on day zero and satisfaction with the anesthesiologist's patient management shows statistical significance (p<0.05). Patients who had a post-operative visit by an anesthesiologists tolerated better preoperative and postoperative physical symptoms. Patients visited by an anesthesiologist were most satisfied with post-operative care (p<0.05). Conclusion: Use of a highly reliable questionnaire for evaluation of patient´s satisfaction with anesthesia could improve the post-operative condition of patients and enable faster recovery during post-operative period.


Introduction
Anesthesiologists around the world work daily to improve the quality of their work, building on their knowledge, skills and following the development of technology that facilitates work and broadens horizons. One of the most important requirements for improving the quality of work for anesthesiologists is insight into patient's experience and satisfaction with anesthesia 1-6 . Patient satisfaction, when it comes to anesthesia, is more difficult to assess than in any other medical specialty. Fear related to anesthesia affects patients more than fear of surgical procedures. Immediately after surgery, patients may have amnesia induced by premedication. A major problem is the relatively short time anesthesiologist spends with their patients. 2 Assessing patient satisfaction with anesthesia is a challenge, because it is a multidimensional concept. [1][2][3] Detection of the adverse events during anesthesia is a relevant step in assessing the patient's satisfaction with anesthesia, but it is not the only indicative factor of the patient's contentment regarding the anesthesia. Patient morbidity and mortality are certainly important for assessing the outcomes, but not appropriate when it comes to assessment of patient´s satisfaction.
Patients seek emotional support from their anesthesiologists, in order to feel safer. 5 Continuous monitoring, evaluation, and adaptation to changes in patients' expectations are the basis for continuous assessment of patient satisfaction with anesthesia. 3 In 2014, the American Association of Anesthesiologists issued recommendations on how to continuously monitor and asses patient satisfaction with anesthesia. 7 They recommended that each hospital around the world should construct a valid psychometric instrument for assessing patient satisfaction with anesthesia. 8 The recommendation highlighted the importance of acquirement of the information about the operating procedure and patients´ demographic data, as well as the construction of a psychometric instrument for assessment of patients´ satisfaction, and its continuous use in the clinical setting. In Europe, the Joint Commission International (JCI) is in charge of monitoring and assessing the quality of healthcare. Part of the quality assessment is insight into the satisfaction of patients provided with health care.
In Republic of Serbia, the quality of healthcare is evaluated on an annual basis by the Ministry of Health. There is specific set of guidelines assessing the quality of health care.
The data collected are general data on every level of health care. When looking at tertiary healthcare institutions, the rulebook generally refers to the quality of surgical procedures, without giving much consideration to anesthesia. The evaluation is performed with assessment of patients' lethality rates, the length of hospital treatment, the total number of patients, and the need for patients to be treated in the intensive care unit (ICU). 9 Aside from the general assessment of patient satisfaction with the treatment in tertiary healthcare institutions, which is centered around surgery, there are no other assessments tools for patient satisfaction and quality of care provided in our country. Anesthesia, without which surgical work or any peri-operative management would not be feasible, should be evaluated according to patients' satisfaction in order to provide better medical care in the future. With that in mind, creating a universal psychometric tool capable of assessing patient satisfaction with anesthesia would be very beneficial for the field.
The aim of this research was to construct a tool for assessing patients' satisfaction with anesthesia, and then examine the effects of post-operative care provided by anesthesiologists on patients' satisfaction with anesthesia, after knee ligament reconstruction.

Methods
The research is a prospective clinical study that includes patients undergoing reconstruction Patients were divided into three groups by a method of random sorting. Randomization plan for treatment assignment to patients was generated using the online randomization (https://www.randomizer.org/). We used simple randomization (based on a single sequence of random assignments), so each participant had an equal chance of being assigned to each group and had been assigned to a group independently of other participants. 10 The tools used in the research were a sociodemographic questionnaire, anesthesia patient satisfaction questionnaire and Post Anesthetic Recovery Scoring System (PAS). [13][14] The anesthesia patient satisfaction questionnaire was constructed for purposes of the study.
The questionnaire was previously validated in a pilot study which included 100 subjects.
Based on the theoretical framework of the study, 21 items were formulated. Using factor analysis, the list of key factors was brought down to 4. The first factor was Satisfaction with the anesthesiologist's relationship with the patient which consists of ten items. The coefficient of reliability was measured to be 0.90 using Cronbach's alpha. The second factor Peri-anesthesia comfort, consists of three items and relates to physical symptoms after surgery, which may be the result of anesthesia. The coefficient of reliability for the second factor was measured to be 0.56 using Cronbach's alpha. The third factor Dissatisfaction with postoperative care consists of five items which focus on the professionalism and behavior of anesthesiologists and other team members before and after surgery. The coefficient of reliability for this factor was measured to be 0.80. The fourth factor Fear of anesthesia consists of three items and relates to the patient's stance on and fear of anesthesia. The coefficient of reliability for the fourth factor was measured to be 0.75. The coefficient of reliability for the entire questionnaire measured on the study sample population using Cronbach's alpha was 0.889. The Peri-anesthesia comfort factor has weaker metrics when compared to the remaining three factors, therefore the questionnaire can be administered without the three items relating to factor two, and the high overall coefficient of reliability for the questionnaire makes it possible to implement a scoring system, which would indicate the patient's satisfaction with anesthesia. During this study all four factors were used in order to have as much insight into patient satisfaction.
During the first phase of the study, basic socio-demographic data was collected and patients were interviewed. A general balanced anesthesia was then administered to the patients during the second phase of the study. In the third phase of the study, one hour after awakening from anesthesia, in the recovery room, Group 1 was visited by the anesthesiologist during the postoperative care, while Group 2 was visited by a nurse anesthetist. Group 3 did not have a visit during post-operative care.
During postoperative visit we objectively (PAS score) and subjectively estimated the state of the patients (Group 1 and 2). The second visit for Groups 1 and 2 was performed on the first day after the surgery and subjective and objective assessment was also performed.
On the second postoperative day, all three groups of the patients were given a questionnaire for measuring patients' satisfaction with anesthesia by a hospital ward nurse who was not involved in the post-operative care. Data were collected using a standardized questionnaire and verified by the author, coded and entered into a specially created database on a personal computer. The basic descriptive statistical parameters used for qualitative and quantitative estimates of the results were: arithmetic mean (X) and standard deviation. Variance analysis (ANOVA) was used for estimating the statistical significance of the difference of obtained results between the groups. Pearson's correlation coefficient was used to examine the relationship between variables. We used factor analysis to determine the factor structure of the questionnaires used. For all tests levels of statistical significance (p values) were specified.

Results
The sample consisted of 218 subjects with a mean age of 29 years (18 to 50 years old). The majority of respondents were male (144 versus 74).
The overall PAS score during the zero post-operative day was an average of 13.20 in the range of 11 to 14, where a lower score indicates worse postoperative condition of the subject. The overall mean PAS score on the first post-operative day was 13.94 in a range from 12 to 14 (Table 1). Based on an objective estimate of the patient's health by the anesthesiologist, following the reconstruction of the ACL, it can be inferred that the patients were in good health.
The overall mean score of the subjective assessment of the post-operative condition during day zero (the indicators were pain, drowsiness, hunger and thirst, body tremors, fainting and headaches, nausea and vomiting, dyspnea, and subjective experience of whether they are feeling well) is 12.16 (maximum possible value for subjective assessment was 16, while patients assessed their condition with maximum of 14 points). The mean subjective assessment score on day zero indicates that subjects were for the most part satisfied with their health and did not experience any major issues.
On the first postoperative day, the overall mean score of subjective assessment was 7.95 in the range from 7 to 10 ( Table 1). The maximum score of 10 during the first postoperative day implies the overall score of the indicators: pain, drowsiness, hunger and thirst, shortness of breath and subjective assessment of whether they feel good. Indicators relating to fainting and headache, nausea and vomiting, as well as body tremors were not measured on the first postoperative day. Patients assessed their subjective condition as excellent on day zero and day one.
Since the subjects reported their post-operative assessments immediately after the surgery and on the first post-operative day, as well as the fact that the PAS score was obtained, which is an objective measure of the patient's condition, a correlation analysis was performed on the data to determine whether there is a relationship between the subjective and objective scores of the patients' post-operative conditions. Based on Table 2 The results of the correlation analysis indicate positive association between the perianesthesia comfort and the subjective assessment of the post-operative state on day zero (Table 3). Based on the results of this analysis, we see that patients who were more satisfied with peri-anesthesia comfort also reported better post-operative health on day zero. On the other hand, patients who were not satisfied with peri-anesthesia comfort, assessed their subjective condition as worse.
To investigate whether there is a relationship between an objective assessment of a patient's post-operative condition and patient satisfaction with anesthesia, we conducted a correlation analysis. Table 4 shows statistically significant positive correlation between an objective assessment of the post-operative condition of patients on day zero and patient´s satisfaction with the anesthesiologist's relationship with them. If the patient is more satisfied with the anesthesiologist's attitude towards him, the objective post-operative condition is better.
Subjective and objective condition of patients after surgery is associated with patient satisfaction with anesthesia. Patients who are objectively better in general condition are more satisfied with the relationship with their anesthesiologist, while the subjective assessment of the patient about post-operative recovery during the day zero is more important for satisfaction on all factors including satisfaction with anesthesia.
To check for statistically significant differences in anesthesia satisfaction between different groups (Group 1, Group2 and Group 3) of patients a one-way analysis of the variance was conducted. Groups were used as independent variables in the analysis, while the four factors related to patient satisfaction with anesthesia were used as dependent variables.
When it came to the Satisfaction with the anesthesiologist's relationship with the patient factor, Group1 was more satisfied than Groups 2 and 3. Also, Group 2 was more satisfied with the relationship of anesthesiologist than Group 3 (Table 5 and Figure1).
There was no statistical significance when examining the Peri-anesthesia Comfort, but based on Figure 2, it can be observed that Group 1 more easily tolerated preoperative and postoperative physical symptoms, and felt more comfortable than the patients of the other two groups.
When it comes to Dissatisfaction with post-operative care, Group 1 was most satisfied with post-operative care in relation to other two groups (Table 5 and Figure 3). Patients in Group 3 had a more pronounced fear of anesthesia than patients from Group 1 ( Table 5). The two groups did not differ statistically from each other, but it can be seen that patients from Group 2 exhibited less fear from anesthesia than patients from Group3 ( Figure 4).

Discussion
The overall PAS score during the zero post-operative day was an average of 13.20 in the range of 11 to 14, where a lower score indicated worse post-operative condition. The overall average PAS score on post-operative day one was 13.94 in a range of 12 to 14.
Based on the objective assessment of post-operative condition of the patients by an anesthesiologists, it can be concluded that the respondents were in good general condition after surgery. Based on the patient population age, ASA score, and the type of surgical intervention, it was expected to see patients in good post-operative condition. The high PAS score amongst the patients correlates well with data found in other literature. [15][16][17] The objective assessment of post-operative condition of patients is extremely important for the further treatment, as well as for early rehabilitation. 18,19 Patients in good general condition -with minimal to no post-operative pain -will be able to tolerate early activation that comes on the first postoperative day after ACL reconstruction more easily. [20][21][22] The way patients feel often correlates well with the objective assessment of their condition. [23][24][25] Patients who are feeling well do not have post-operative pain and side effects of anesthesia, hence their subjective assessment of their condition will be good. [26][27] In this study, showed a statistically significant correlation between the subjective and objective condition of the patient with the patient's satisfaction with anesthesia. 31 As in the study by Saal et al., where significant differences in the level of satisfaction with anesthesia between groups were recorded, statistically significant differences were also found in our study. 32 In our study, Group 1 scored higher when it came to factors such as Satisfaction with the anesthesiologist´s relationship with the patient and Peri-anesthesia comfort when compared to other two groups.
Subjects were also asked about their fear of anesthesia, with 52.8% of subjects stating they felt fear of anesthesia. More than half of the subjects felt fear of anesthesia prior to the surgery, and the control group (Group 3) in the post-operative period had higher scores on the Fear of anesthesia factor. This result validates data from literature where level of fear of anesthesia is significantly higher in groups, which did not have a post-operative visit by an anesthesiologist. 33,34 Amongst the study population, Group 3, which had no postoperative visit, had the highest score when it came to Dissatisfaction with post-operative care. In the study by Saal et al. the experimental group, which had a post-operative visit by an anesthesiologist, scored higher with regards to the Continuous care by an anesthesiologist and Trust. There is no statistically significant difference between the groups which were visited by an anesthesiologist and medical technician from the department. 32 There is a statistically significant difference between groups when it comes to Satisfaction with the anesthesiologist´s relationship with the patients, Fear from anesthesia and Dissatisfaction with post-operative care.
When it came to the Satisfaction with the anesthesiologist´s relationship with the patients, patients in Group 1 were more satisfied with this aspect than patients in other two groups.
Also, patients in Group 2 were more satisfied with the relationship with the anesthesiologist than the control group. In the study by Saal et al a statistically significant difference was observed only when compared to the control group, no significant difference was observed between the groups that were visited by an anesthesiologist and medical technician. 32 Ateleanu and Sultan observed a statistically significant difference in post-operative visits between anesthesiologists and other members of the anesthesiology team. 33.35 There was no statistically significant difference between groups with regards to the assessment of Peri-anesthesia comfort, however, one can infer that the patients, who were visited by an anesthesiologist, handled pre-and post-operative symptoms with more ease, and consequently felt more comfortable than the other two groups.
When it comes to Dissatisfaction with post-operative care, Group 3 significantly differs from the other two experimental groups. Patients in Group 3 were more dissatisfied with post-operative care. Group 1, which was visited by an anesthesiologist, was the most satisfied with post-operative care of all groups. The additional attention provided by an anesthesiologist helps the patient to feel safer and more satisfied with post-operative care.
When looking at patient satisfaction with anesthesia, literature highlights the importance of the care provided by an anesthesiologist. 34.36.37 Patients in Group 3 felt a more pronounced fear of anesthesia when compared to patients of Group 1. Group 1 and 2 did not differ significantly from each other. Patients in Group 2 showed lower levels of fear of anesthesia in comparison to patients from Group 3. The presence of an anesthesiologist, who explains to patients the anesthesia procedure and who is there to answer any possible questions, contributes to the reduction of anxiety and stress, and represents a form of preoperative preparation which is very important for the patient's experience of surgery and for later post-operative recovery. 32.35,38 Data from literature, which focuses on the importance of a post-operative visits, indicates a statistically significant difference between patients who had a post-operative visit from anesthesiologists and those who did not. [36][37][38][39][40][41][42][43][44][45] The importance of a post-operative anesthesiologist's work is undeniable when considering patient's satisfaction with anesthesia. 46

Conclusion
Greater satisfaction with the anesthesiologist's relationship to the patient, as well as with post-operative care and less pronounced fear of anesthesia in the subjects of the experimental group visited by anesthesiologist, highlight the importance of proper communication with patients, that is communication of patients with the person they previously saw during the anesthesia procedure. A visit by the anesthesiologist who administered the anesthesia makes patients feel safer. This consequently increases the patient's level of satisfaction with the anesthesia, and even more so the level of satisfaction with post-operative care and the relationship between the patient and the medical staff, more specifically with the anesthesiologist. We also constructed a highly reliable questionnaire for evaluating patient satisfaction with anesthesia, which can be readily used in a clinical setting in our region. These results give us guidance for further work of the anesthesiologists in order to improve the post-operative care and enable faster recovery, which is a consequence of the patient's greater satisfaction with anesthesia and postoperative care.   Yes, by ward nurse